基于患者选择模型分级诊疗的困境研究

发布时间：2018-03-17 03:08

本文选题：分级诊疗　切入点：基层首诊　出处：《南京大学》2017年硕士论文　论文类型：学位论文

【摘要】：在2009年新医改"强基层,建机制"的思路指导下,国家一直致力于推进分级诊疗的制度建设,希望通过强化基层医疗机构建设,引导患者选择基层就诊,缓解大医院的诊疗压力。然而患者的就医行为并没有因为分级诊疗政策发生显著变化,相反大型公立医院在医疗市场的垄断地位日益凸显,总诊疗人次占比近5年来一路攀升,人才领先优势愈发明显。国家也曾试图拉大不同层级医院的报销比例,利用经济手段提高基层医疗机构的吸引力,政策效果不甚理想:大医院人满为患,基层门可罗雀的现象未得到有效改观,"看病贵、看病难"的痼疾依然存在。本文的研究目的就是回答在分级诊疗的政策背景下,在国家对基层医疗机构投入大量财政经费,推行诸多优惠政策的情况下,患者为何仍然倾向于去大医院就医,分级诊疗的实施困境该如何解决。区别于一些西方国家强制性基层首诊的制度安排,中国患者拥有自主就医的选择权利。分级诊疗的突破口在于改变偏好大医院居民的就医习惯,让他们在患病后愿意选择基层医疗机构就诊。为此本文以患者行为作为研究的切入点,首先厘清患者医疗机构选择的供方因素、需方因素及相互关系,以此构建患者选择模型,着重关注医疗供方的"质量"和"价格"对患者选择的影响。通过模型推导提出患者就医选择中质量、价格效应的研究假设,并选取《中国家庭追踪调查》(CFPS)2010、2012、2014年三期面板数据进行实证分析。本文利用固定效应和随机效应方法研究患者选择的质量效应,选取甘肃省分级诊疗的价格实验采取倍差法研究患者选择的价格效应,模型加入滞后项探讨患者就医选择的行为惯性,采用倾向得分匹配法进行分级诊疗的政策评估。得出如下结论:(1)基层服务质量是影响患者医疗机构选择的核心要素;(2)健康偏好能够调节患者选择中质量效应的大小;(3)患者就医选择存在收入效应,医疗服务价格的引导作用有限;(4)患者就医选择具有"棘轮效应";(5)分级诊疗在有效"控费"的同时,不会降低患者的治疗效果。患者的就医选择经历了从"就医意愿"转化为"就医行为",最后形成"就医习惯"的过程,根据实证研究的结论,本文提出三条针对性政策建议:(1)加强政策宣传,患者"愿意去";(2)提升基层质量,患者"信得过";(3)注重互动交流,患者"留得住"。
[Abstract]:In 2009, under the guidance of the new medical reform, "strengthen the grassroots, build the mechanism", the country has been committed to promoting the hierarchical diagnosis and treatment system construction, hoping to strengthen the construction of grass-roots medical institutions, leading patients to choose grass-roots care. Relieving the pressure of diagnosis and treatment in large hospitals. However, the behavior of patients seeking medical treatment has not changed significantly as a result of the graded diagnosis and treatment policy. On the contrary, the monopoly position of large public hospitals in the medical market has become increasingly prominent, and the total number of visits has been rising in the past five years. The country has also tried to increase the reimbursement ratio of hospitals at different levels and used economic means to increase the attractiveness of primary medical institutions. The policy effect has not been satisfactory: large hospitals are overcrowded. The phenomenon of the grass roots has not been effectively improved, and the chronic disease of "seeing a doctor is expensive but difficult to see a doctor" still exists. The purpose of this paper is to answer that, in the context of the policy of graded diagnosis and treatment, the state has invested a large amount of financial funds in primary medical institutions. Under the circumstances of many preferential policies, why do patients still tend to go to major hospitals for medical treatment, and how to solve the difficulties in the implementation of graded diagnosis and treatment? this is different from the system arrangement of mandatory first-time consultations at the grass-roots level in some Western countries. Chinese patients have the right to choose their own medical treatment. The breakthrough in graded diagnosis and treatment lies in changing the habits of residents who prefer large hospitals. So that they are willing to choose primary medical institutions to see a doctor after the illness. Therefore, this paper regards patient behavior as the starting point of the study, first of all, to clarify the supplier factors, demand-side factors and the relationship between patients' medical institutions, so as to build a patient selection model. Focusing on the effect of "quality" and "price" on patients' choice, the research hypothesis of quality and price effect in patients' choice of medical treatment is put forward through model derivation. The panel data of three issues of CFPS 2010 / 2012, 2014 were selected for empirical analysis. The qualitative effects of patients' selection were studied by the methods of fixed effect and random effect. In the price experiment of graded diagnosis and treatment in Gansu Province, the price effect of patient selection was studied by double difference method, and the behavioral inertia of patient's choice of medical treatment was studied by adding lag term into the model. It is concluded that the quality of primary care is the core factor influencing the selection of patients' medical institutions. Health preference can adjust the quality effect of patients' selection. There is income effect in patients' choice of medical treatment. The guiding effect of medical service price is limited. 4) the choice of medical treatment for patients has "ratchet effect" and "ratchet effect". Patients' choice of medical treatment experienced a process from "willingness to seek medical treatment" to "behavior of seeking medical treatment", and finally formed "habit of seeking medical treatment", according to the conclusion of empirical research. This paper puts forward three specific policy suggestions: 1) strengthen the policy propaganda, the patient "willing to go" to improve the basic level quality, the patient "trustworthy" 3) pays attention to the interactive exchange, the patient "can stay".
【学位授予单位】：南京大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R197.1

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